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Seeburruth D, Tong XC, Kirwan C, Ramsden S, Kibria A, Carter J, Huang J, McArthur R, Clayton N, de Wit K. Eligibility for anticoagulation initiation in atrial fibrillation: Agreement between emergency physician and medical record review. Acad Emerg Med 2024. [PMID: 38456355 DOI: 10.1111/acem.14889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/04/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Darshana Seeburruth
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - X Catherine Tong
- Department of Family Medicine, McMaster University, Kitchener-Waterloo, Ontario, Canada
| | - Christopher Kirwan
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sophie Ramsden
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aqsa Kibria
- Royal College of Surgeons in Ireland (RCSI), Bahrain
| | - Jaimie Carter
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Johnny Huang
- Department of Family Medicine, McMaster University, Kitchener-Waterloo, Ontario, Canada
| | - Robyn McArthur
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Natasha Clayton
- Emergency Department, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
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Addy K, Joyce LR, Al-Busaidi IS, Pickering JW, Troughton R, Than M. Implementation of an integrated emergency department acute atrial fibrillation pathway safely reduces cardioversions and hospitalisations: A comparative pre-post study. Emerg Med Australas 2023; 35:828-833. [PMID: 37169715 DOI: 10.1111/1742-6723.14240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Atrial fibrillation/flutter (AF/AFL) accounts for high rates of ED presentations and hospital admissions. There is increasing evidence to suggest that delaying cardioversion for acute uncomplicated AF is safe, and that many patients will spontaneously revert to sinus rhythm (SR). We conducted a before-and-after evaluation of AF/AFL management after a change in ED pathway using a conservative 'rate-and-wait' approach, incorporating next working day outpatient clinic follow-up and delayed cardioversion if required. METHODS We performed a before-and-after retrospective cohort study examining outcomes for patients who presented to the ED in Christchurch, New Zealand, with acute uncomplicated AF/AFL in the 1-year period before and after the implementation of a new conservative management pathway. RESULTS A total of 360 patients were included in the study (182 'Pre-pathway' vs 178 'Post-Pathway'). Compared to the pre-pathway cohort, those managed under the new pathway had an 81.2% reduction in ED cardioversions (n = 32 vs n = 6), and 50.7% reduction in all cardioversions (n = 65 vs n = 32). There was a 31.6% reduction in admissions from ED (n = 54 vs n = 79). ED length of stay (3.9 h vs 3.8 h, net difference -0.1 h, 95% confidence interval [CI] -0.6 to 0.3), 1-year ED AF representation (32.4% vs 26.4%, net difference -6.0% [95% CI -16.0% to 3.9%]), 1-year ED ischaemic stroke presentation (2.2% in both groups) and 7-day all-cause mortality rates (hazard ratio 1.05 [95% CI 0.6 to 1.9]) were all similar. CONCLUSIONS Using a conservative 'rate-and-wait' strategy with early follow-up for patients presenting to ED with AF/AFL can safely reduce unnecessary cardioversions and avoidable hospitalisations.
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Affiliation(s)
- Kaleb Addy
- Department of General Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
| | - Laura R Joyce
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ibrahim S Al-Busaidi
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand
- Department of Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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3
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Carter J, Kirwan C, Niaz S, Baweja S, Al-Haimus F, Hu Y, Ramsden S, Clayton N, de Wit K. Anticoagulation prescription among atrial fibrillation patients managed with and without an anticoagulant initiation pathway: a cohort study. Eur J Emerg Med 2023; 30:365-370. [PMID: 37598348 DOI: 10.1097/mej.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND IMPORTANCE The Canadian Association of Emergency Physicians atrial fibrillation (AF) checklist advises that emergency physicians initiate anticoagulation therapy for patients with AF or flutter who are CHADS65 positive. OBJECTIVES The aim was to compare anticoagulation initiation rates between patients treated with and without an anticoagulation assessment pathway (the SAFE pathway). DESIGN This was a retrospective cohort study. SETTINGS AND PARTICIPANTS All emergency department patients were discharged home with a diagnosis of AF between June 2018 and May 2020 at two Canadian emergency departments. INTERVENTION The SAFE pathway is a hard copy form which allows emergency physicians to document contraindications to anticoagulation, the positive components of the CHADS65 score, and details how to prescribe anticoagulation. OUTCOME MEASURES AND ANALYSIS Trained researchers abstracted data on the use of the SAFE pathway by the presence or absence of the completed, scanned pathway in the electronic medical chart. The exposure of interest was use of this pathway. Patients were followed forward in time for 90 days by electronic medical record review to document stroke, transient ischemic attack, arterial embolism and major bleeding events. All events were independently adjudicated. Adjusted odds ratios were calculated to compare outcomes between those managed with and without the SAFE pathway. RESULTS In total, 766 patients were included, of whom 264 were already taking anticoagulation, 166 were CHADS65 negative and 65 had a contraindication to anticoagulation, leaving 271 patients eligible for anticoagulation prescription. Among the 271 eligible patients, 137/166 managed with the SAFE pathway were initiated on anticoagulation and 24/105 managed without the SAFE pathway started anticoagulation (adjusted odds ratio 25.9; 13.1-51.2). There was no statistically significant difference in the 90-day rate of stroke or bleeding. CONCLUSION Use of the SAFE pathway was associated with a higher rate of anticoagulation prescription.
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Affiliation(s)
- Jaimee Carter
- Department of Family Medicine, Queen's University, Kingston
| | | | - Saghar Niaz
- Department of Medicine, McMaster University, ON
| | - Shriya Baweja
- Department of Anatomy and Cell Biology, McGill University, Montreal, QC
| | - Fayad Al-Haimus
- Division of Emergency Medicine, Department of Medicine, University of Toronto, ON
| | - Yang Hu
- Department of Medicine, McMaster University, ON
| | - Sophie Ramsden
- Division of Emergency Medicine, Department of Medicine, McMaster University
| | - Natasha Clayton
- Department of Medicine, McMaster University
- Emergency Department, Hamilton Health Sciences, Hamilton
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University
- Departments of Emergency Medicine and Medicine, Queen's University, Kingston
- Department of HEI McMaster University, Hamilton, ON, Canada
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4
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Manzo-Silberman S, Chouihed T, Fraticelli L, Charpentier S, Claustre C, Bonnefoy-Cudraz E, Elbaz M, Peiretti A, Taboulet P, Waintraub X, Roubille F, El Khoury C. Assessment of atrial fibrillation in European emergency departments: insights from a prospective observational multicenter study. Minerva Cardiol Angiol 2023; 71:444-455. [PMID: 36422468 DOI: 10.23736/s2724-5683.22.06179-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND The diagnosis and management of atrial fibrillation (AF) in emergency departments (EDs) have not been well described in France, with limited EU research. This study aimed to describe the diagnosis, management, and prognosis of AF patients in French EDs. METHODS A prospective, observational 2-month study in adults diagnosed with AF was conducted at 32 French EDs. Data regarding patient characteristics, diagnosis, and treatment at EDs were collected, with 12-month follow-up. RESULTS The study included a total of 1369 patients diagnosed with AF at an ED: 279 patients (20.4%) with idiopathic AF (no identified cause of the AF) and 1090 (79.6%) with secondary AF (with a principal diagnosis identified as the cause of AF). Patients were aged 84 years (median) and 51.3% were female. Significantly more idiopathic AF patients than secondary AF patients underwent CHA<inf>2</inf>DS<inf>2</inf>-VASc assessment (67.8% vs. 52.1%,) or echocardiography (21.2% vs. 8.3%), or received an oral anticoagulant and/or antiarrhythmic (62.0% vs. 12.9%). Idiopathic AF patients also had significantly higher rates of discharge to home (36.4% vs. 20.4%) and 3-month cardiologist follow-up (67.0% vs. 41.1%). At 12 months, 96% of patients with follow-up achieved sinus rhythm. The estimated Kaplan-Meier 12-month mortality rate was significantly lower with idiopathic AF than secondary AF (11.9% vs. 34.5%). CONCLUSIONS Patients diagnosed with idiopathic or secondary AF at the ED presented heterogeneous characteristics and prognoses, with those with secondary AF having worse outcomes. Further studies are warranted to optimize patients' initial evaluation in EDs and provide appropriate follow-up.
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Affiliation(s)
- Stéphane Manzo-Silberman
- Institute of Cardiology, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, ACTION Study Group, Paris, France -
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, University of Lorraine, Vandoeuvre-les-Nancy, France
- Cliniques-Inserm 1433 Investigation Center, Inserm UMR_S 1116, F-CRIN INI-CRCT, Vandoeuvre-les-Nancy, France
| | - Laurie Fraticelli
- Auvergne Rhône-Alpes Agency for Health, RESCUe Network, Lyon, France
- EA4129, Systemic Health Pathway Laboratory, Lyon, France
| | | | - Clément Claustre
- Auvergne Rhône-Alpes Agency for Health, RESCUe Network, Lyon, France
| | | | - Meyer Elbaz
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | | | - Pierre Taboulet
- Emergency Department, Saint-Louis Hospital, AP-HP, Paris, France
| | - Xavier Waintraub
- Institute of Cardiology, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, ACTION Study Group, Paris, France
| | - François Roubille
- Department of Cardiology, Montpellier University Hospital, Montpellier, France
| | - Carlos El Khoury
- Clinical Research Unit, Emergency Department, Médipôle Hôpital Mutualiste, Lyon, France
- HESPER EA7425, University Lyon1, Lyon, France
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5
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Vinson DR, Rauchwerger AS, Karadi CA, Shan J, Warton EM, Zhang JY, Ballard DW, Mark DG, Hofmann ER, Cotton DM, Durant EJ, Lin JS, Sax DR, Poth LS, Gamboa SH, Ghiya MS, Kene MV, Ganapathy A, Whiteley PM, Bouvet SC, Babakhanian L, Kwok EW, Solomon MD, Go AS, Reed ME. Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial). Trials 2023; 24:246. [PMID: 37004068 PMCID: PMC10064588 DOI: 10.1186/s13063-023-07230-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION ClinicalTrials.gov NCT05009225 . Registered on 17 August 2021.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA.
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chandu A Karadi
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Judy Shan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jennifer Y Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Dale M Cotton
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Edward J Durant
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, CA, USA
| | - James S Lin
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Dana R Sax
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Luke S Poth
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | - Stephen H Gamboa
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Meena S Ghiya
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, CA, USA
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
| | - Anuradha Ganapathy
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Patrick M Whiteley
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Sean C Bouvet
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | | | | | - Matthew D Solomon
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Cardiology, Oakland Medical Center, Oakland, CA, USA
| | - Alan S Go
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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6
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Islam S, Dover DC, Daniele P, Hawkins NM, Humphries KH, Kaul P, Sandhu RK. Sex Differences in the Management of Oral Anticoagulation and Outcomes for Emergency Department Presentation of Incident Atrial Fibrillation. Ann Emerg Med 2022; 80:97-107. [DOI: 10.1016/j.annemergmed.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/25/2022] [Accepted: 03/08/2022] [Indexed: 11/01/2022]
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Yuguero O, Cabello I, Arranz M, Guzman JA, Moreno A, Frances P, Santos J, Esquerrà A, Zarauza A, Mòdol JM, Jacob J. Emergency Department capacity to initiate thromboprophylaxis in patients with atrial fibrillation and thrombotic risk after discharge: URGFAICS cohort analysis. Intern Emerg Med 2022; 17:873-881. [PMID: 34677788 DOI: 10.1007/s11739-021-02864-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/28/2021] [Indexed: 11/24/2022]
Abstract
Atrial fibrillation (AF) is the most prevalent heart rhythm disorder in the general population. Stroke prevention is one of the leading management objectives in the treatment of AF patients. The variables associated with the non-initiation of thromboprophylaxis in patients with thrombotic risk consulting for an episode of AF in Emergency Departments (ED) were investigated. This was a multipurpose, analytical, non-interventionist, multicenter Spanish study with a prospective 30-day follow-up. All patients ≥ 18 years of age consulting to the ED for the casual finding of AF in an electrocardiogram (ECG) performed 12 h prior to the consultation or with symptoms related to AF were enrolled from September 1, 2016 to February 28, 2017. Patients not previously received thromboprophylaxis were selected. Multivariate analysis was performed to calculate the odds ratio (OR) and the 95% confidence interval (CI). A total of 634 patients, not received thromboprophylaxis and at high thrombotic risk, were included. Of these, 251 (39.6%) did not receive thromboprophylaxis at ED discharge. In the multivariate analysis, non-initiation of anticoagulation at discharge from the ED was mostly related to cognitive impairment (OR 3.95; (95% CI 2.02-7.72), cancer history (OR 2.12; (95%CI 1.18-3.81), AF duration < 48 h (OR 2.49; (95% CI 1.48-4.21) and patients with re-establishment of sinus rhythm (OR 3.65; (95% CI 1.47-9.06). Reinforcement of the use of CHA2DS2-VASC as a stroke risk scale and empowerment of ED physicians is a must to improve this gap in care.
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Affiliation(s)
- Oriol Yuguero
- Emergency Department, Hospital Arnau de Vilanova, Lleida, Spain
| | - Irene Cabello
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain.
| | - María Arranz
- Emergency Department, Hospital de Viladecans, Viladecans, Barcelona, Spain
| | | | - Anna Moreno
- Emergency Department, Hospital Arnau de Vilanova, Lleida, Spain
| | - Paloma Frances
- Emergency Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Julia Santos
- Emergency Department, Hospital de Viladecans, Viladecans, Barcelona, Spain
| | - Anna Esquerrà
- Emergency Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Alvaro Zarauza
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain
| | - Josep-Maria Mòdol
- Emergency Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain
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8
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Johnson LSB, Oldgren J, Barrett TW, McNaughton CD, Wong JA, McIntyre WF, Freeman CL, Murphy L, Engström G, Ezekowitz M, Connolly SJ, Xu L, Nakamya J, Conen D, Bangdiwala SI, Yusuf S, Healey JS. LVS-HARMED Risk Score for Incident Heart Failure in Patients With Atrial Fibrillation Who Present to the Emergency Department: Data from a World-Wide Registry. J Am Heart Assoc 2021; 10:e017735. [PMID: 34514842 PMCID: PMC8649506 DOI: 10.1161/jaha.120.017735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Heart failure (HF) is a common complication to atrial fibrillation (AF), leading to rehospitalization and death. Early identification of patients with AF at risk for HF might improve outcomes. We aimed to derive a score to predict 1-year risk of new-onset HF after an emergency department (ED) visit with AF. Methods and Results The RE-LY AF (Randomized Evaluation of Long-Term Anticoagulant Therapy) registry enrolled patients with AF presenting to an ED in 47 countries, and followed them for a year. The end point was HF hospitalization and/or HF death. Among 15 400 ED patients, 9765 had no prior HF (mean age, 64.9±14.9 years). Within 1 year, new-onset HF developed in 6.8% of patients, of whom 21% died of HF. Independent predictors of HF included left ventricular hypertrophy (odds ratio [OR], 1.47; 95% CI, 1.19-1.82), valvular heart disease (OR, 1.55; 95% CI, 1.18-2.04), smoking (OR, 1.42; 95% CI, 1.12-1.78), height (OR, 0.93; 95% CI, 0.90-0.95 per 3 cm), age (OR, 1.11; 95% CI, 1.07-1.15 per 5 years), rheumatic heart disease (OR, 1.77, 95% CI, 1.24-2.51), prior myocardial infarction (OR, 1.85; 95% CI, 1.45-2.36), remaining in AF at ED discharge (OR, 1.86; 95% CI, 1.46-2.36), and diabetes (OR, 1.33; 95% CI, 1.09-1.64). A continuous risk prediction score (LVS-HARMED [left ventricular, valvular heart disease, smoking or other tobacco use, height, age, rheumatic heart disease, myocardial infarction, emergency department discharge rhythm, and diabetes]) had good discrimination (C statistic, 0.735; 95% CI, 0.716-0.755). Validation was conducted internally using bootstrapping (optimism-corrected C statistic, 0.705) and externally (C statistic, 0.699). The 1-year incidence of HF hospitalization and/or HF death across quartile groups of the score was 1.1%, 4.5%, 6.9%, and 14.4%, respectively. LVS-HARMED also predicted incident stroke (C statistic, 0.753; 95% CI, 0.728-0.778). Conclusions The LVS-HARMED score predicts new-onset HF after an ED visit for AF. Preventative strategies should be considered in patients with high LVS-HARMED HF risk.
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Affiliation(s)
- Linda S B Johnson
- Department of Clinical Physiology Skåne University Hospital Department of Clinical Sciences Lund University Malmö Sweden.,Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
| | - Tyler W Barrett
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN
| | - Candace D McNaughton
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN.,Geriatric Research, Education, and Clinical Center Tennessee Valley Healthcare System VA Medical System Nashville TN
| | - Jorge A Wong
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - William F McIntyre
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Clifford L Freeman
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN
| | - Laura Murphy
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN
| | - Gunnar Engström
- Department of Clinical Physiology Skåne University Hospital Department of Clinical Sciences Lund University Malmö Sweden
| | - Michael Ezekowitz
- Sidney Kimmel Medical College Bryn Mawr HospitalLankenau Heart Center Wynnewood PA
| | - Stuart J Connolly
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Lizhen Xu
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Juliet Nakamya
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - David Conen
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | | | - Salim Yusuf
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
| | - Jeff S Healey
- Population Health Research Institute McMaster University Hamilton Onatrio Canada
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9
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Mendoza PA, McIntyre WF, Belley-Côté EP, Wang J, Parkash R, Atzema CL, Benz AP, Oldgren J, Whitlock RP, Healey JS. Oral anticoagulation for patients with atrial fibrillation in the ED: RE-LY AF registry analysis. J Thromb Thrombolysis 2021; 53:74-82. [PMID: 34338944 DOI: 10.1007/s11239-021-02530-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/27/2022]
Abstract
Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF). We sought to determine predictors of OAC initiation in AF patients presenting to the emergency department (ED). Secondary analysis of the RE-LY AF registry which enrolled individuals from 47 countries between 2007 and 2011 who presented to an ED with AF and followed them for 1 year. A total of 4149 patients with AF as their primary diagnosis who were not already taking OAC and had a CHA2DS2-VASc ≥ 1 for men or ≥ 2 for women were included in this analysis. Of these individuals, 26.8% were started on OAC (99.2% vitamin K antagonists) in the ED and 29.8% were using OAC one year later. Factors associated with initiating OAC in the ED included: specialist consultation (relative risk [RR] 1.84, 95%CI 1.44-2.36), rheumatic heart disease (RR 1.60, 95%CI 1.29-1.99), persistence of AF at ED discharge (RR 1.33, 95%CI 1.18-1.50), diabetes mellitus (RR 1.32, 95%CI 1.19-1.47), and hospital admission (RR 1.30, 95%CI 1.14-1.47). Heart failure (RR 0.83, 95%CI 0.74-0.94), antiplatelet agents (RR 0.77, 95%CI 0.69-0.84), and dementia (RR 0.61, 95%CI 0.40-0.94) were inversely associated with OAC initiation. Patients taking OAC when they left the ED were more likely using OAC at 1-year (RR 2.81, 95%CI 2.55-3.09) and had lower rates of death (RR 0.55, 95%CI 0.38-0.79) and stroke (RR 0.59, 95%CI 0.37-0.96). In patients with AF presenting to the ED, prompt initiation of OAC and specialist involvement are associated with a greater use of OAC 1 year later and may result in improved clinical outcomes.
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Affiliation(s)
- Pablo A Mendoza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - William F McIntyre
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, ON, Canada
| | - Ratika Parkash
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | | | - Jonas Oldgren
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard P Whitlock
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Population Health Research Institute, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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10
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Niaz S, Kirwan C, Clayton N, Mercuri M, de Wit K. Anticoagulation for newly diagnosed atrial fibrillation and 90-day rates of stroke and bleeding. CAN J EMERG MED 2021; 23:325-329. [PMID: 33959927 DOI: 10.1007/s43678-020-00054-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/28/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Atrial fibrillation increases the risk of stroke, which can be mitigated by anticoagulant prescription. We evaluated local emergency physician anticoagulation practice for patients discharged from the emergency department with atrial fibrillation, along with 90-day incidence of stroke and major bleeding. METHODS This was a health record review of patients diagnosed with new onset atrial fibrillation in two emergency departments between 2014 and 2017. We collected data on CHADS65 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), systemic embolism or major bleeding within 90 days. RESULTS We identified 399 patients, median age 68 (IQR 57-79), 213 (53%) male. Only 299/399 patients had an indication for anticoagulation (CHADS65-positive). Of these 299, 27 had a contraindication to or were already prescribed anticoagulation. 45/272 (17%, 95% confidence interval 12-22%) patients eligible for initiation of anticoagulation left the emergency department with a prescription for anticoagulation. During 90-day follow-up, seven patients had stroke or TIA. Four stroke/TIA patients had been eligible to start an anticoagulant but were not started, two left the emergency department with prescriptions for an anticoagulant and one patient had a contraindication to initiating anticoagulation in the emergency department. There were no major bleeding episodes. CONCLUSION Few eligible patients were prescribed anticoagulation and the 90-day stroke rate was high. Physicians should become familiar with the CAEP Acute AF Best Practices Checklist AF which offers guidance on anticoagulation prescription.
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Affiliation(s)
- Saghar Niaz
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Chris Kirwan
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
| | - Mathew Mercuri
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.
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11
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 299] [Impact Index Per Article: 74.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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12
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Atzema CL, Jackevicius CA, Chong A, Dorian P, Ivers NM, Parkash R, Austin PC. Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation. CMAJ 2020; 191:E1345-E1354. [PMID: 31818927 DOI: 10.1503/cmaj.190747] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Patients with atrial fibrillation frequently seek emergency care. Rates of guideline-concordant oral anticoagulant therapy for stroke prevention are suboptimal in the community. We assessed the association between prescribing of oral anticoagulants in the emergency department (relative to referral to a longitudinal care provider for treatment initiation) and long-term use of oral anticoagulants. METHODS This retrospective cohort study performed at 15 hospitals in Ontario, Canada, involved patients aged 65 years or older who visited the emergency department between 2009 and 2014, who had a primary diagnosis of atrial fibrillation, were discharged home, and were eligible for and willing to take stroke-prevention therapy. We used inverse probability-of-treatment weighting based on the propensity score to compare patients who were and were not given a prescription for an oral anticoagulant. The primary outcome was a prescription fill for an oral anticoagulant 6 months later. Secondary outcomes included a prescription fill at 1 year, all-cause mortality, and strokes or bleeding events leading to hospital admission. RESULTS Of 2132 eligible patients, 402 (18.9%) were given a prescription for an oral anticoagulant in the emergency department. After weighting, 67.8% of these patients had filled a prescription for an oral anticoagulant at 6 months versus 37.2% of those who did not receive a prescription in the emergency department (absolute risk increase [ARI] 30.6%, number needed to treat [NNT] 3). At 1 year, the ARI was 23.2% and the NNT was 4. Rates of death, stroke and bleeding events did not differ significantly. INTERPRETATION In patients with atrial fibrillation who were eligible for stroke prevention, prescribing an oral anticoagulant in the emergency department was associated with substantially higher long-term use of oral anticoagulants compared with deferring to the longitudinal care provider to initiate this therapy. Physicians working in the emergency department should consider initiating oral anticoagulation in eligible patients who are being discharged to home.
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Affiliation(s)
- Clare L Atzema
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Cynthia A Jackevicius
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Alice Chong
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Paul Dorian
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Noah M Ivers
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Ratika Parkash
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Peter C Austin
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
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13
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Rush KL, Burton L, Ollivier R, Wilson R, Loewen P, Janke R, Schaab K, Lukey A, Galloway C. Transitions in Atrial Fibrillation Care: A Systematic Review. Heart Lung Circ 2019; 29:1000-1014. [PMID: 32094081 DOI: 10.1016/j.hlc.2019.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) commonly transition between care settings and providers. These transitions are often points in the health care system where errors and clinical deterioration can occur. Anticoagulation interruption or discontinuation and sub-optimal follow-up post-emergency department (ED) discharge are considered major transitional issues. OBJECTIVE The purpose of this study was to synthesise the evidence examining the impact of transitional care interventions on patient, provider, and health care utilisation outcomes. METHODS This systematic mixed studies review examined citations from four databases Medline, CINAHL, EMBASE, and Cochrane Central Controlled Register of Trials (CENTRAL) using relevant search terms. Fourteen (14) moderate to high quality articles were selected. RESULTS The available evidence reporting impacts of transitional interventions on health care utilisation, provider, and patient outcomes in AF patients is mixed and of variable quality. The stronger evidence revealed improvements in patient outcomes including knowledge, quality of life, and medication adherence and increased provider anticoagulant prescriptions resulting from transitional interventions. Hospital admissions and ED visits were not significantly affected by any interventions. CONCLUSIONS Apps and educational toolkits improved patient knowledge. Pathways increased patient quality of life and provider prescription rates. There is a need for more research to determine the AF transition interventions which maximise patient, provider and health care outcomes.
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Affiliation(s)
- Kathy L Rush
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada.
| | - Lindsay Burton
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Rachel Ollivier
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Ryan Wilson
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Robert Janke
- Library, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Kira Schaab
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Alexandra Lukey
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Camille Galloway
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
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14
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Affiliation(s)
- Jeff S Healey
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - William F McIntyre
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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15
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Freeman CL, Barrett TW. Stop the Clot: Should Emergency Clinicians Champion Stroke Prevention and Prescribe Anticoagulation for Patients With Atrial Fibrillation? Ann Emerg Med 2019; 73:419-421. [DOI: 10.1016/j.annemergmed.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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